Living Will

Before you fill it in

Replace every bracketed field, keep the options you agree on and remove the rest.

Write specific treatment preferences in your own words and discuss how they will be recorded with your care team.

Advance-care forms and witnessing requirements differ; this worksheet does not replace a required official form.

Full template · same text in Word and PDF

Effective date: [DATE]. Complete the bracketed fields and remove unused options before signing.

Person making this statement: [FULL LEGAL NAME], [ADDRESS], [NOTICE EMAIL].

1. IDENTITY AND CONTACTS

Full name and date of birth: [DETAILS]. Address: [DETAILS]. Emergency contact: [NAME / DETAILS]. Healthcare representative, if separately appointed: [NAME / DOCUMENT REFERENCE]. Treating clinician contact, if desired: [DETAILS].

2. WHEN THESE WISHES APPLY

Situations in which these wishes are intended to apply: [SPECIFIC CONDITIONS]. How the applicable conditions and decision-making capacity are to be assessed: [DETAILS CONSISTENT WITH REQUIRED PROCESS]. While able to decide, my current choices take priority as applicable law provides.

3. TREATMENT PREFERENCES

Treatments I would accept in the specified circumstances: [DETAILS]. Treatments I would refuse in those circumstances: [DETAILS]. Preferences about resuscitation, ventilation, artificial nutrition or hydration, and comfort care, if I choose to address them: [SEPARATE SPECIFIC INSTRUCTIONS]. Unaddressed treatment choices are not automatically refused.

4. VALUES AND INTERPRETATION

Personal values, religious wishes, people to consult and other instructions: [DETAILS]. Resolve uncertainty through [CONTACT / PROCESS]. This statement does not itself appoint a healthcare decision-maker or serve as a clinical emergency-treatment order where a separate document is required.

5. COPIES, CHANGES AND SIGNING

Copies provided to: [NAMES / LOCATIONS]. Previous documents replaced, if any: [DETAILS]. Review or change record: [DATE / DETAILS]. Complete required form, capacity, witness and other formalities: [DETAILS]. Revocation and notification follow applicable requirements.

EXECUTION RECORD

Date and place: [DETAILS]. Required witnesses and declarations: [COMPLETE REQUIRED TEXT AND SIGNATURES]. Any required acknowledgment or additional form: [REFERENCE].

SIGNATURES

Person making this statement: [NAME]

Signature: ____________________ Date: ____________________

Signing capacity, if applicable: [TITLE / CAPACITY]